Provider Demographics
NPI:1033141890
Name:GRANDE CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:GRANDE CHIROPRACTIC LLC
Other - Org Name:GRANDE CHIROPRACTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRANDE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:410-451-9870
Mailing Address - Street 1:2411 CROFTON LN
Mailing Address - Street 2:SUITE 14A
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-1304
Mailing Address - Country:US
Mailing Address - Phone:410-451-9870
Mailing Address - Fax:410-451-9872
Practice Address - Street 1:2411 CROFTON LN
Practice Address - Street 2:SUITE 14A
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-1304
Practice Address - Country:US
Practice Address - Phone:410-451-9870
Practice Address - Fax:410-451-9872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD111N00000X111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
269PMedicare PIN